A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?

An expected side effect of the medication

An allergic reaction to the nitroglycerin

A sign that the medication should not be used again

An indication of worsening cardiac condition

Answer and Explanation

The Correct Answer is A

Choice A reason: A headache is a common and expected side effect of nitroglycerin. Nitroglycerin causes vasodilation, which can lead to increased blood flow to the head and result in headaches. It is important to inform the client that this is a known side effect and to manage it with appropriate measures, such as taking analgesics.

Choice B reason: An allergic reaction to nitroglycerin would typically present with symptoms such as rash, itching, swelling, or difficulty breathing. A headache alone does not indicate an allergic reaction.

Choice C reason: A headache does not mean the medication should not be used again. It is a common side effect, and the benefits of nitroglycerin in relieving chest pain usually outweigh the discomfort of the headache. The nurse should educate the client on managing the headache while continuing the medication.

Choice D reason: A headache is not an indication of a worsening cardiac condition. It is a common side effect of the vasodilatory effects of nitroglycerin.

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Correct Answer is D

Explanation

Choice A reason: Dilated pupils are not a clinical manifestation of hypocalcemia. Hypocalcemia primarily affects the neuromuscular system, leading to symptoms such as muscle cramps and tetany. Pupillary changes are not commonly associated with low calcium levels.

Choice B reason: Hyperactive bowel sounds are not typically associated with hypocalcemia. While hypocalcemia can lead to muscle spasms and cramps, it does not usually cause changes in gastrointestinal motility. Hyperactive bowel sounds may be related to other gastrointestinal disorders.

Choice C reason: Hyperglycemia is not a clinical manifestation of hypocalcemia. Hypocalcemia affects calcium levels in the blood and neuromuscular function. Hyperglycemia is related to elevated blood sugar levels and is not directly connected to calcium metabolism.

Choice D reason: Positive Chvostek's sign is a clinical manifestation of hypocalcemia. This sign is elicited by tapping on the facial nerve, causing twitching of the facial muscles. It is an indication of neuromuscular irritability due to low calcium levels.

A. The client is able to repeat three whispered words without difficulty. B. The client is able to tack the unlock on the left ear versus the right ear when placed on top of the head. C. The client will display minimal swaying when standing with feet together and eyes closed. D. The client will hear the tuning fork for a longer period when placed next to the ear than when placed behind the ear on the mastoid process.

Correct Answer is D

Explanation

Choice A reason: The ability to repeat three whispered words without difficulty is an assessment of auditory acuity, not a specific finding of the Rinne test. The Rinne test evaluates bone and air conduction of sound.

Choice B reason: Placing the tuning fork on top of the head is part of the Weber test, which assesses lateralization of sound. It is not part of the Rinne test.

Choice C reason: Minimal swaying when standing with feet together and eyes closed is an assessment of balance, known as the Romberg test. It is not related to the Rinne test.

Choice D reason: The Rinne test compares air conduction (next to the ear) with bone conduction (on the mastoid process). Normally, air conduction is heard longer than bone conduction, indicating normal hearing or sensorineural hearing loss. This is the correct expected finding for the Rinne test.

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A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?